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Section 6: Each person who hereafter becomes a member of the Cooperative, and such person who is a member on the effective date of this bylaw and continues his membership thereafter, by such act alone, consents that the amount of any distributions of net proceeds made in the form of written notices of allocation will be taken into account by him at their stated dollar amounts in the taxable year in which such written notices of allocation are received by him.

*** By granting consent, you are agreeing to account to the federal government any income you may receive as the result of receiving a patronage dividend.

Certification: Under the penalties of perjury, I certify that the information provided on this form is true, correct and complete. I further grant consent as it applies to Article V, Sec. 6 of the Articles of Incorporation of Midland Services, Inc.

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Under the Federal income tax law, you are subject to a 28% withholding tax on all patronage dividends if you have not provided us with your correct social security number or other taxpayer identification number.

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Coop Patron Number Application

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